Survival after percutaneous endoscopic gastrostomy among older residents of Quebec

Factors Associated with 30-Day Mortality in Patients after Percutaneous Endoscopic Gastrostomy

Introduction:

Percutaneous endoscopic gastrostomy (PEG) is the main accepted method for long-term tube feeding. The aim of this study is to investigate the risk factors associated with early mortality after PEG.

Methods:

It is a retrospective survival analysis in a tertiary-level hospital. We reviewed the medical records of 277 patients with PEG placement. The data were analyzed by the Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of PEG on mortality.

Results:

A total of 277 patients who submitted to PEG were studied. One-hundred and sixty (58%) were female, mean age of 73.3 ± 15.7 years. Ninety-three patients (33.6%) had diabetes mellitus and 165 (59.6%) had blood hypertension. The indications for PEG placement were chronic neurologic dysphagia in 247 (89.5%) patients and tumors and other diseases in 29 (10.5%). The 30 days proportional mortality probability rate was 13%. In a multivariate Cox proportional regression model, preoperative ICU hospitalization (HR 1.79, 95% CI 1.36–2.36, P = 0.000) and hemoglobin (HR 0.91, 95% CI 0.85–0.98, P = 0.015) were predictors of early mortality.

Conclusion:

In patients who had underwent PEG tube insertion for long-term nutrition, anemia and previous ICU admission were predictors of mortality at four weeks. These factors may guide physicians to discourage the indication for PEG.

RISK FACTORS ASSOCIATED WITH EARLY MORTALITY AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN PATIENTS AT A TERTIARY CARE CENTER IN BRAZIL: A RETROSPECTIVE SINGLE-CENTER SURVIVAL STUDY

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is the main accepted method for long-term tube feeding.

OBJECTIVE

To investigate the risk factors associated with early mortality after PEG.

METHODS

Retrospective survival analysis in a tertiary-level center in Recife, Brazil. We reviewed the medical records of 150 patients with PEG placement. The data were analysed by the Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of PEG on mortality.

RESULTS

A total of 150 patients who submitted to PEG were studied (70 male). Of the participants, 87 (58%) had blood hypertension; 51 (34%) patients had diabetes; 6 (4%) patients had chronic renal disease; and 6 (4%) had malignancy. Chronic neurodegenerative diseases were the more common clinical indication for PEG. The 30-day and 60-day proportional mortality probability rates were 11.05% and 15.34% respectively. A multivariate Cox proportional regression model, haemoglobin (HR 4.39, 95%CI 1.30-14.81, P=0.017) and pre-procedure UCI staying (HR 0.66, 95% CI 0.50-0.87, P=0.004) were significant predictors of early mortality.A haemoglobin cut-off value of 10.05 g/dL was shown to have a sensibility of 82.6% (61.2% to 95% CI) and an acceptable sensitivity of 59.0 (50.6% to68.6% CI), and a likelihood ratio of 2.06 for eight weeks mortality.

CONCLUSION

In patients who had been subjected to the PEG procedure for long-term nutrition, low haemoglobin, pre-procedure intensive care unit internment or both are associated with the risk of early mortality.

A Successful Percutaneous Endoscopic Gastrostomy Tube Feeding over Two Decades with No Complication: A Rare Case Report

Percutaneous endoscopic gastrostomy (PEG) feeding is a common and widely performed procedure appropriate for long-term enteral nutrition in patients with multiple indications. We present the case of a 59-year-old woman with a PEG tube placed owing to complication following thyroid surgery approximately 20 years ago, representing the most extended duration of PEG tube feeding without any significant complication for chronic mechanical dysphagia. This case highlights the importance of PEG feeding, where this route can be used indefinitely in an appropriate clinical setting without complications. Interestingly, self-replacement of PEG tube was performed by the patient herself whenever she noticed clogging up of tube while self-feeding.

Percutaneous endoscopic gastrostomy for aspiration pneumonia: A 10-year single-center experience

BACKGROUND

The significance of percutaneous endoscopic gastrostomy (PEG) in patients with aspiration pneumonia is unknown. The purpose of this study was to evaluate the clinical characteristics and outcomes of aspiration pneumonia patients who underwent PEG.

METHODS

A retrospective cohort study of consecutive patients hospitalized with pneumonia who underwent PEG from 2005 to 2014.

RESULTS

Of 2281 cases of pneumonia, 92 patients with aspiration pneumonia underwent PEG during their hospital stay. The rate of PEG insertion significantly decreased after 2011, when Japanese therapeutic guidelines for pneumonia in the elderly were published (5.9% vs. 1.6% before and after guideline publication, respectively; p<0.01). The study population was male dominant (63%), with a mean age of 80.7 years. They had several risk factors for aspiration pneumonia, such as dementia (63.0%), cerebrovascular disorders (37.0%), and neurologic diseases (28.3%). Survival after PEG was 88.0% at day 30, 84.3% at 3 months, 73.8% at 6 months, and 61.1% at 1 year with a median survival of 751 days. Pneumonia was the most common cause of death during the follow-up period (22 of 51 patients, 43.1%). Cox proportional hazard model showed that independent predictors of mortality were older age, male gender, comorbidity of heart failure, and lower serum albumin values before PEG.

CONCLUSIONS

The rate of PEG placement is decreasing after the Japanese guidelines were published in 2011. While the overall median survival was approximately 2 years, the most common cause of death was pneumonia and mortality was associated with some significant factors.

Comparison of short-term mortality and morbidity between parenteral and enteral nutrition for adults without cancer: a propensity-matched analysis using a national inpatient database

BACKGROUND

Proper artificial nutrition for patients who are unable to eat normally is an ongoing, unresolved concern in geriatric medicine and home medical care. Controversy surrounds prognostic differences between parenteral and enteral nutrition, 2 methods for artificial nutrition.

OBJECTIVES

Short-term outcomes of parenteral and enteral nutrition for patients who are unable to eat normally were compared and analyzed.

DESIGN

Data were acquired from patients selected from a national inpatient database covering 1057 hospitals in Japan. Participants had received artificial nutrition between April 2012 and March 2013, were aged ≥20 y, and did not have cancer. They were separated into 2 groups: those who received parenteral nutrition and those who received enteral nutrition. We performed one-to-one propensity score matching between the groups. The primary outcome measurements were mortality rates at 30 and 90 d after the start of the procedure. The secondary outcomes were postprocedural complications, pneumonia, and sepsis. We analyzed survival length of stay after the procedure with the use of a Cox proportional hazards model.

RESULTS

There were 3750 patients in the parenteral group and 22,166 patients in the enteral group. Propensity score matching created 2912 pairs in the 2 groups. Patients with a similar propensity score (probability of being assigned to the enteral group) calculated from the baseline condition were matched. Mortality rates at 30 and 90 d after start of treatment were 7.6% and 5.7% (P = 0.003) and 12.3% and 9.9% (P = 0.002) in the parenteral and enteral groups, respectively. In Cox regression analysis, the HR for the enteral group relative to the parenteral group was 0.62 (95% CI: 0.54, 0.71; P < 0.001). The incidences of postprocedural pneumonia and sepsis were 11.9% and 15.5% (P < 0.001) and 4.4% and 3.7% (P = 0.164) for the parenteral and enteral groups, respectively.

CONCLUSION

The present analysis showed the better survival rate with enteral compared with parenteral nutrition for adults who were not suffering from cancer. This trial was registered at clinicaltrials.gov as NCT02512224.

Is short-term percutaneous endoscopic gastrostomy tube placement beneficial in acutely ill cognitively intact elderly patients? A proposed decision-making algorithm

AIM

Percutaneous endoscopic gastrostomy (PEG) tube is an important method of enteral feeding for patients who require temporary or long-term artificial nutritional support to prevent or correct disease-related malnutrition. However, there is paucity of data on the utility of short-term PEG tube placements in acute illnesses in cognitively intact older adults.

METHODS

We present a series of seven, cognitively intact patients (age range 72-93 years), who had PEG tubes placed for short periods. These patients were diagnosed with "failure to thrive" and were managed by placing a PEG tube temporarily for nutritional management. None of these patients had terminal illness or hospice eligibility, and all of the patients were community dwellers.

RESULTS

All of the elderly patients experienced good outcomes in terms of their functional status and nutritional support.

CONCLUSIONS

Our series clearly supports the notion that short-term PEG tube placement in cognitively intact elderly patients could be a successful strategy to support them during an episode of acute illness, and to improve their nutritional deficits and survival.

[Age at the time of gastrostomy placement as a prognostic factor in long-term hospitalized patients]

OBJECTIVE

To evaluate the influence of age at the time of gastrostomy placement as a prognostic factor and examine the survival rate in long-term hospitalized patients with gastrostomy.

METHODS

The subjects were 408 inpatients with gastrostomy admitted to our hospital between December 2005 and March 2012. All inpatients, including the present subjects, received oral care in the form of attendant care by nurses or caregivers. First, the subjects were divided into two groups according to sex. Second, the subjects were divided into four groups according to the age at the time of gastrostomy placement: the sixties group (60-69 years), seventies group (70-79 years), eighties group (80-89 years), and nineties group (90-99 years). Each survival curve was drawn using the Kaplan-Meier method, and the log-rank tests were used for statistical analysis. The Cox proportional hazard models were used to calculate hazard ratios.

RESULTS

The overall survival rates at one year and five years after gastrostomy placement were 75.4% and 23.2%, respectively. The median survival period was 32.2 months. A significantly better prognosis was observed in women than in men; the age-adjusted hazard ratio was 1.748 (95% CI, 1.364-2.242) for men. The eighties and nineties groups exhibited significantly poorer prognoses than that of the sixties group (p<0.008); the sex-adjusted hazard ratios were 2.173 (95% CI, 1.341-3.521) and 3.071 (95% CI, 1.627-5.797), respectively.

CONCLUSIONS

These results suggest that oral care, even after gastrostomy placement, can improve the prognosis in patients with gastrostomy. Physicians should therefore be cautious when recommending gastrostomy placement for patients aged>80 years.

In-hospital and long-term outcomes after percutaneous endoscopic gastrostomy in patients with malignancy

BACKGROUND

Although percutaneous endoscopic gastrostomy (PEG) is widely performed for nutrition or palliation, PEG-associated outcomes in cancer patients remain poorly described. We examined the safety and benefits of PEG placement in this population at our institution.

STUDY DESIGN

A 5-year retrospective review of patients with malignancy (excluding head/neck and thoracic malignancy) who underwent PEG at our institution was performed.

RESULTS

One hundred and eighty-nine patients with malignancy underwent PEG; 33.9% had hematologic malignancy, 66.1% had nonhematologic malignancy, and 44.4% had metastatic disease. Indications for PEG were enteral access (73%) and gastric decompression/management of obstructive symptoms (27%). Few patients achieved independence from total parenteral nutrition (22%) or diet advancement (24.6%). Overall rates of major complications (eg, aspiration, tube dislodgement/leakage, bleeding, visceral injury, respiratory failure after procedure, and cardiac arrest) and minor complications (eg, superficial infection and ileus) were 10.2% and 11.3%, respectively. All-cause in-hospital mortality was high (19.6%) and was associated with ICU admission (p = 0.018), earlier bone marrow transplantation (p = 0.022), steroid treatment (p = 0.024), and lower preoperative albumin (p = 0.003). Code status was changed after PEG in 44 patients from full code to DNR/do no intubate or comfort measures only.

CONCLUSIONS

Percutaneous endoscopic gastrostomy placement in this study population was associated with major procedure-related complications. The majority of patients failed to achieve total parenteral nutrition independence or advancement of diet. Nearly 25% of patients declined aggressive resuscitation strategies after undergoing surgery for PEG. This study cautions to carefully weigh the risks and benefits of PEG placement in this patient population. Prospective studies are needed to uncover factors affecting the decision process and patient selection.

Indications for percutaneous endoscopic gastrostomy and survival in old adults

Background

Many diseases striking old adults result in eating difficulties. Indications for selecting individuals for percutaneous endoscopic gastrostomy (PEG) are unclear and everybody may not benefit from the procedure.

Objective

The aim of this study was to evaluate indications for and survival after PEG insertion in patients older than 65 years.

Design and Methods

A retrospective analysis including age, gender, diagnosis, indication, and date of death was made in 201 consecutive individuals, 94 male, mean age 79±7 years, who received a nutritional gastrostomy.

Results

Dysphagia was present in 86% of the patients and stroke was the most common diagnosis (49%). Overall median survival was 123 days and 30-day mortality was 22%. Patients with dementia and Mb Parkinson had the longest survival (i.e. 244 and 233 days), while those with other neurological diseases, and head and neck malignancy had the shortest (i.e. 75 and 106 days). There was no difference in mortality in patients older or younger than 80 years, except in patients with dementia.

Conclusions

Old age should not be a contraindication for PEG. A high 30-day mortality indicates that there is a need of better criteria for selection and timing of PEG insertion in the elderly.

Survival of geriatric patients after percutaneous endoscopic gastrostomy in Japan

AIM: To examine the long term survival of geriatric patients treated with percutaneous endoscopic gastrostomy (PEG) in Japan.

METHODS: We retrospectively included 46 Japanese community and tertiary hospitals to investigate 931 consecutive geriatric patients (≥ 65 years old) with swallowing difficulty and newly performed PEG between Jan 1st 2005 and Dec 31st 2008. We set death as an outcome and explored the associations among patient’s characteristics at PEG using log-rank tests and Cox proportional hazard models.

RESULTS: Nine hundred and thirty one patients were followed up for a median of 468 d. A total of 502 deaths were observed (mortality 53%). However, 99%, 95%, 88%, 75% and 66% of 931 patients survived more than 7, 30, 60 d, a half year and one year, respectively. In addition, 50% and 25% of the patients survived 753 and 1647 d, respectively. Eight deaths were considered as PEG-related, and were associated with lower serum albumin levels (P = 0.002). On the other hand, among 28 surviving patients (6.5%), PEG was removed. In a multivariate hazard model, older age [hazard ratio (HR), 1.02; 95% confidence interval (CI), 1.00-1.03; P = 0.009], higher C-reactive protein (HR, 1.04; 95% CI: 1.01-1.07; P = 0.005), and higher blood urea nitrogen (HR, 1.01; 95% CI: 1.00-1.02; P = 0.003) were significant poor prognostic factors, whereas higher albumin (HR, 0.67; 95% CI: 0.52-0.85; P = 0.001), female gender (HR, 0.60; 95% CI: 0.48-0.75; P < 0.001) and no previous history of ischemic heart disease (HR, 0.69; 95% CI: 0.54-0.88, P = 0.003) were markedly better prognostic factors.

CONCLUSION: These results suggest that more than half of geriatric patients with PEG may survive longer than 2 years. The analysis elucidated prognostic factors.

Resumption of oral intake following percutaneous endoscopic gastrostomy

BACKGROUND AND AIMS

Percutaneous endoscopic gastrostomy (PEG) provides enteral nutrition to patients who cannot swallow. Few studies have prospectively evaluated its long-term outcomes or eventual resumption of oral intake.

METHODS

Consecutive PEG patients were prospectively recruited from a tertiary hospital over 12 months and followed until all had met the primary endpoints of death or resumption of oral diet with PEG extubation. Data was collected by standardised periodic phone interview.

RESULTS

Forty patients (24 males, median age 74 years) were followed for up to 8.4 years (median 5.3 months, interquartile range [IQR] 13.6 months). The end-of-study mortality rate was 70% (median 6.8 months, IQR 19.9 months) and the only predictor of mortality was head injury as the indication for PEG (Cox regression HR 5.90, 95% CI: 1.2-28.4). At two years following PEG, 30% of patients had resumed oral intake (median 2.9 months, IQR 7.2 months) and 19% remained on PEG-feeding. Predictors of resumption of oral intake were the ability to tolerate some oral intake at 3 months (HR: 248.5, 95% CI: 8.7-7065.3) and 6 months (HR: 6.3, 95% CI: 1.03-38.9) but not at 12 months. Cumulative survival was highest for ear nose and throat (ENT) tumour and worst for acute head injury (log rank P = 0.048).

CONCLUSIONS

Half of all PEG patients remained alive at 2 years using PEG or have resumed full oral intake. A supervised trial of oral intake at 3 or 6 months may help predict eventual resumption of per oral diet.

Physicians' expectations of benefit from tube feeding

OBJECTIVE

Tube feeding is increasingly common, despite evidence for limited medical benefits. We interviewed treating physicians to describe their expectation of benefit for patients receiving a new feeding tube, and to determine whether expected benefits vary by patient characteristics.

METHODS

We recruited treating physicians and surrogate decision-makers for 288 hospitalized patients in a prospective study of new feeding tube decisions. In structured interviews, physicians provided information on patients' diagnosis and whether they expected any of eight potential medical benefits for a specific patient; surrogates provided information about the patients' function, race, age, prior residence, and ability to eat by mouth.

RESULTS

We completed interviews with 173 physicians about tube feeding for 280 patients (response rate, 97%). Patients commonly had acute stroke (30%), neurodegenerative disease (16%), or head and neck cancer (22%); 70% were somewhat or severely malnourished. In half or more cases, physicians expected benefits of improved nutrition (93%), hydration (60%), prolonged life (58%), ease providing medication (55%), and less aspiration risk (49%). Physicians endorsed more expected benefits for patients with stroke or those completely unable to eat by mouth (p < 0.05).

CONCLUSION

Treating physicians expected multiple medical benefits for a diverse population of patients receiving feeding tubes. Physicians may be unaware of evidence, or expect more optimistic outcomes for their specific patient population. Further education and decision support may improve evidence-based decision-making about feeding tubes.

A better method for preventing infection of percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has been widely used to maintain enteral nutrition in dysphagic patients. Local and occasional life-threatening systemic infections are still the most common complications, and the major infection source may be nosocomial flora. The effect of antibiotic prophylaxis on reducing peristomal infection is popularly accepted. However, it is accompanied with a possible risk of increasing antibiotic resistance.

AIM

This study attempted to determine whether 14-day discharge before PEG could reduce the rate of peristomal infection.

MATERIALS AND METHODS

Fifty patients who had received PEG in our hospital were included in this study and followed for at least 6 months (except for those patients who died during this period). Patients were separated into two groups randomly. Twenty-five patients received PEG during in-hospitalization (group A). The other 25 patients received PEG until discharge at least for 14 days (group B). The most frequent indication for PEG insertion was the neurological condition. Risk factors for peristomal infection were analyzed statistically using logistic regression and expressed by odds ratios. Every possible factor was analyzed by chi-square test or Student's t test.

RESULT

Our data showed that group A had a higher peristomal infection rate than group B (32 vs 8%) (p < 0.05). Group A also showed more need of antibiotics. The risk factors related to peristomal infection were group A and lower albumin. The total rate of 30-day mortality was 4%.

DISCUSSION

When compared with previous data, our study showed a similar infection rate in group A, a lower infection rate in group B, and a lower 30-day mortality rate. This meant that one period of discharge could reduce the peristomal infections caused by colonized bacteria. It also decreased the need of using antibiotics and might avoid the possible adverse consequence of promoting bacterial resistance, which is an alarming and growing problem in hospital practice.

CONCLUSION

We suggest that a 14-day grace period after discharge, before PEG insertion, may decrease peristomal infection rate, length of hospital stay after PEG, and the need for antibiotics. This is suitable for moral and ethical considerations.

Long-term outcome following placement of percutaneous endoscopic gastrostomy in younger and older patients

OBJECTIVE

Percutaneous endoscopic gastrostomy (PEG) is the method of choice in maintaining enteral nutrition in patients with swallowing and nutritional disorders of different etiology. The aim of this study was to assess the long-term outcome of patients following placement of a PEG.

MATERIAL AND METHODS

All patients who received a PEG between October 1999 and September 2000 were included in this prospective study. Long-term function, replacement or removal of the PEG, complications and survival of the patients were analyzed in group A (younger than 75 years) and group B (75 years or older).

RESULTS

The indications for PEG placement in group A (54 patients, mean age 54.5 years) were neurological (66.7%) and malignant (31.5%) disorders, whereas in group B (40 patients, mean age 81 years) the indications were predominantly neurological diseases (87.5%). The majority of patients (91 of 94 patients; 96.8%) could be followed long term or until death. In group A, 46 patients (85.2%) had uncomplicated long-term function of their PEG and interventions were necessary in only 8 patients. Removal of the PEG was possible during the course in 17 patients (31.5%). In group B, uncomplicated long-term function was observed in 34 patients (85%) and interventions were required in only 6 patients. Removal of the PEG was not possible in group B. Survival rates for 1-, 2- and 5 years in group A were 73.9%, 61.8% and 43.9%, respectively, and in group B 41.4%, 31.9% and 15.9%, respectively; the difference was statistically significant (p=0.002).

CONCLUSIONS

Excellent long-term function of PEG was seen in this study of 94 consecutive patients, and interventions were necessary only in a minority of patients. The prognosis for older patients was worse; however, the 2-year survival rate of 32% justified the PEG insertion.

A patient with dementia and cancer: to feed via percutaneous endoscopic gastrostomy tube or not?

Despite the lack of clear benefits of feeding via gastrostomy tube in dementia patients, its use has been increasing. The views of health professionals, patients and their carers differ widely about the perceived benefits, which makes decision-making difficult and stressful. The palliative care approach of facilitating better communication and end-of life care planning can help avoid inappropriate gastrostomy tube placements. A case of an elderly male with dementia and two malignancies is described, and the place of the palliative care approach is explored.

Expectations and outcomes of gastric feeding tubes

PURPOSE

To compare expected outcomes with actual outcomes from tube feeding in adult patients.

SUBJECTS AND METHODS

This prospective cohort study was conducted in two North Carolina hospitals. Surrogates were interviewed shortly after feeding tube insertion and at 3- and 6-month follow-up; chart abstraction and death certificate review also were carried out. Participants were surrogate decision-makers for consecutive adult patients who received new feeding tubes.

RESULTS

There were 288 patients with surrogate decision-makers enrolled. Mean age was 65 years; 30% had a primary diagnosis of stroke, 16% neurodegenerative disorder, 20% head and neck cancer, and 30% other diagnoses. At 3 months, 21% of patients had died, and 6-month mortality was 30%. At 3 months, 38% of survivors were residing in a nursing home, and 27% had the feeding tube removed. Patients were impaired in most activities of daily living (ADLs) with little change over time. Medical complications were common: 25% of patients had decubitus ulcers at 3 months, and 24% had at least one episode of pneumonia. Perceived global quality of life was poor at 4.6 (on a 0-10 scale) at baseline, and surrogates anticipated this would improve to 8.0 with tube feeding. Family surrogates' expectations for improvement from the feeding tube were very high at baseline and remained so at 3 and 6 months.

CONCLUSIONS

Families' high expectations of benefit from tube feeding are in contrast to clinical outcomes. Providers and families need better information about the outcomes of this common procedure.

Gastrostomy and Jejunostomy Placement: The Urban Hospital Perspective Pertinent to Nursing Home Care

OBJECTIVES

In nursing home settings, providers often think that most percutaneous endoscopic gastrostomy (PEG) tubes are placed in older people, some perhaps inappropriately. We sought to describe the relationships between patient age and the indications for, the decision making behind, and the outcomes of gastrostomy and jejunostomy placement in an urban hospital to give perspective to those of us working in long-term care settings.

DESIGN

Retrospective, observational study.

SETTING

Urban hospital.

PARTICIPANTS

Two hundred thirty-nine inpatients who underwent gastrostomy or jejunostomy (G/J) placement.

MEASUREMENTS

Hospital records were reviewed for patient demographics, disease process, decision making, and short-term outcomes associated with G/J placement. Mortality at 30 days and 1 year was obtained by a search of the National Death Index. The prevalence of these variables in those aged 65 years and older was compared to the prevalence in those younger than 65 with associations calculated both unadjusted and adjusted for gender, place of residence, underlying condition, and Charlson comorbidity index.

RESULTS

Patients who were aged 65 years and older were more likely to be female with more comorbid illnesses and were more likely to have had a stroke that precipitated their difficulty eating. They were more likely to have been referred by a medical specialist, to have been seen by a speech pathologist, and to have had their procedure without general anesthesia. The older patients had a shorter mean hospital length of stay with fewer complications but had higher mortality rates at 30 days and 1 year.

CONCLUSION

Patient age was associated with gender and type of disease process and may have influenced the decisions made during the hospital stay. Despite a higher burden of chronic illness, older patient age was not associated with adverse short-term outcomes but was associated with higher mortality rates after discharge.

Ethics and gastrointestinal artificial feeding

Medical ethics is the study of human values as they relate to the practice of medicine. Ethics intersects with gastroenterology primarily involving issues of gastric and intestinal artificial feeding at the end of life. Language imparts meaning. Gastric artificial feeding is not the same as eating. Recent data suggest that gastric artificial feeding does not prolong life in patients with dementia and dysphagia. Given the lack of documented benefit of gastrointestinal feeding in these patients, the literature has focused on selection of appropriate patients for this medical intervention. Ethical care involves compassion, communication, consultation, and collaboration in dealing with emotionally difficult circumstances.

Trends in the use of feeding tubes in North Carolina hospitals

OBJECTIVE

National data describing the placement of feeding tubes demonstrated a rapid increase in use in the early and mid-1990s. In the past several years, substantial concerns have arisen regarding the appropriateness of the procedure in many chronically ill patients. The purpose of this study is to determine whether the use of feeding tubes has continued to increase through the 1990s despite these widely publicized concerns.

DESIGN

Repeated measure cross-sectional study of the North Carolina Discharge Database.

SETTING

Analyses of all nonfederal hospital inpatient admissions in North Carolina.

MEASUREMENTS AND MAIN RESULTS

We examined the absolute numbers and rates of feeding tube placements from 1989 to 2000. The rate of feeding tube placement increased from 59/100,000 persons in 1989 to 94/100,000 persons in 2000, an overall 60% increase with slowing in the rate of increase in the late 1990s. However, when outpatient procedures were included, the increase in tube feeding continued throughout the 11-year period of observation. The increase was due to an increase in utilization within all hospitals over the time period. Utilization did not differ between profit and not for profit hospitals. The relative growth rate of inpatient feeding tube placement did not differ by age group but the absolute increase was greatest in those age 75 years and over.

CONCLUSIONS

Our study demonstrates that the use of feeding tubes has continued to increase through the 1990s. This increase occurred despite ongoing controversy in the medical literature about feeding tube placement in chronically ill patients.

Outcome of percutaneous endoscopic gastrostomy (PEG): comparison of two policies in a 4-year experience

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is the technique of choice for long-term enteral nutrition. Though safe and technically simple, PEG has been associated with significant morbidity and mortality.

AIM

We compared the outcome of strategies applied in two different periods; the original approach of PEG insertion during hospitalization (upon request), and PEG insertion 30 days after hospital discharge.

METHODS

A cohort of 127 patients scheduled for PEG insertion from 1.1.1997 to 31.12.2000, was evaluated. In 61 consecutive patients admitted from 1.1.1997 to 31.12.1998 the PEG insertion was planned during hospitalization, as close to the time of the physician's request (period 1). Sixty-six consecutive patients admitted from 1.1.1999 to 31.12.2000 were scheduled for the PEG insertion 30 days after discharge (period 2). The 30-day mortality rate was calculated from the time of the request. Univariate and multivariate analyses were used to find predictive factors for 30-day mortality.

RESULTS

There were 61 patients with a mean age of 78+/-13 in period 1, and 66 patients with a mean age of 77.8+/-15.5 in period 2. There was no significant difference between patients of the two periods in regard to age, sex, underlying disease, nutritional and mental status. Patients received PEG 30 days after hospital discharge had a 40% lower 30-day mortality rate than patients who received PEG during hospitalization from the time of request for PEG (P=0.01) and a 87.5% lower rate when calculated from the time of insertion (P<0.0001). In-hospital PEG insertion, bed-ridden and disorientation were found to be independent factors predictive of 30-day mortality after PEG insertion (P=0.016,P=0.001, and P=0.0005, respectively).

CONCLUSION

PEG insertion during hospitalization increases mortality and should be avoided. A grace period of 30 days with nasogastric tube feeding before PEG insertion may prevent mortality and achieve a long-term enteral nutrition.

Evidence-based approach to management of fever in patients with end-stage dementia

Alzheimer's dementia and related dementias are incurable illnesses for which curative treatment currently does not exist, and the efficacy of remittive treatment is extremely limited. Persons with advanced dementia commonly develop fever and are at high risk for death. We preformed a systematic review of outcome following fever in patients with advanced Alzheimer's dementia and developed evidence-based recommendations for the treatment of fever in this population of patients. We use a case example to illustrate our discussion.

An assessment of open access referral for percutaneous endoscopic gastrostomy in a district general hospital

OBJECTIVE

To determine the indications, technical success and outcomes of open access percutaneous endoscopic gastrostomy (PEG) insertion in the district general hospital setting.

DESIGN

This study was a retrospective audit of patients receiving PEG by the thread pull method from November 1998 to November 1999, followed by a prospective audit of patients receiving PEG from December 1999 to May 2000. Prophylactic antibiotics were not used. Patient data were collected using a computerized endoscopy unit record system. Clinical assessment was performed and case notes were reviewed. Whenever necessary, telephone follow-up of patients in the community was performed.

PARTICIPANTS

Sixty-five consecutive, unselected patients underwent PEG and 64 were followed up for a total of 7799 patient days. Fifty-seven of 64 (89%) were in-patients. The median age of the patients was 74 years (range, 26-95 years).

MAIN OUTCOME MEASURES

Indications, technical success, early complications and long-term outcomes of PEG.

RESULTS

Cerebrovascular disease was the most common indication for PEG (35/64 (55%)). Technical success was achieved in 62/64 (97%) patients. No serious complications from the procedure were reported: PEG site infection was rare (1/64). Pneumonia was uncommon (8/64 (12.5%)). There were eight (12.5%) deaths during the first week after PEG insertion and 18/64 (28%) during the first month. Mortality at 1 year was 36/64 (56%). Ten of 64 patients (16%) recovered to PEG removal; 18 (28%) continue to be fed via PEG.

CONCLUSION

This audit demonstrates that referral patterns, technical success and long-term outcome of open access referral for PEG in a district general hospital setting are consistent with published series from specialist and tertiary referral centres.

Percutaneous endoscopic gastrostomy and outcome in dementia

The use of percutaneous endoscopic gastrostomy for the administration of food and medications in patients with dementia has been on an increase. Many studies have failed to demonstrate the positive outcome expected of this feeding modality for the indications that required tube placement. Hence, the concept of feeding through gastrostomy tubes has become the subject of much discussion and controversy in recent times. We have reviewed the literature with regard to outcome in older patients with dementia and percutaneous endoscopic gastrostomy with respect to nutritional parameters, quality of life, and survival. A brief discussion on ethical and legal aspects is included. Much of the data do not suggest that outcome in dementia is favorably improved after percutaneous gastrostomy.

Survival after percutaneous endoscopic gastrostomy placement in older persons

BACKGROUND

The prolongation of life is an important consideration in the decision to initiate long-term tube feeding. This report critically synthesizes the evidence regarding the impact of percutaneous endoscopic gastrostomy (PEG) tube placement on survival in older persons.

METHODS

A systematic search was conducted using MEDLINE from January 1980 until January 1999. Articles reporting survival data in older persons (mean or median age >65 years) after PEG tube placement were identified. The number and age of subjects, length of follow-up, setting, and survival data were extracted from all eligible studies. Mortality data at 1, 2, 6, and 12 months after PEG placement were quantitatively synthesized. Clinical characteristics associated with decreased survival among subjects with PEG tubes were identified.

RESULTS

Five cohort studies compared survival in patients with and without feeding tubes in nursing homes, but none demonstrated a survival benefit. Another cohort study reported increased survival for tube-fed patients with amyotrophic lateral sclerosis. The pooled proportion of all subjects surviving after PEG placement was as follows: 1 month = 0.81 (95% confidence interval [CI], 0.74-0.88), 2 months = 0.70 (95% CI, 0.65-0.74), 6 months = 0.56 (95% CI, 0.20-0.92), and 12 months = 0.38 (95% CI, 0.26-0.49). Advanced age and malignancy were the factors most often reported to be associated with poorer survival among subjects with PEG tubes.

CONCLUSIONS

The impact of PEG placement on survival is not known because the level of evidence is limited. PEG tubes may prolong life in selected populations. However, the majority of older patients selected for PEG placement will not survive 1 year after the procedure. Certain factors may identify those patients more likely to derive a survival benefit from long-term tube feeding. This information may offer some guidance to decision makers for whom prolongation of life is an important factor in the tube-feeding decision.

Interventional procedures

During the past year, numerous articles were published on interventional procedures of the stomach, focusing on upper gastrointestinal tract bleeding, gastric cancer, gastric outlet obstruction, and benign disease. In the area of upper gastrointestinal tract bleeding, early endoscopy is warranted for early therapeutic intervention and for triage. In patients with bleeding related to peptic ulcer disease, combination therapy (epinephrine injection in conjunction with electrocoagulation therapy) remains the standard of care. Hemoclipping is a new technique that may be helpful in cases in which conventional therapy fails. Repeat endoscopy should always be considered in patients in whom the first attempt at endoscopic therapy fails. In patients with bleeding related to portal hypertension, prophylactic antibiotics may decrease the risk of infections. Banding remains the therapy of choice for this group of patients. There is no documented benefit for combination therapy (banding and sclerotherapy). Transjugular intrahepatic portosystemic shunts may be helpful in the treatment of hypertensive portal gastropathy but not gastric vascular ectasias. In the area of gastric cancer, management revolves around staging. This can be accomplished best through the use of CT scan and endoscopic ultrasound. In patients with early limited disease, attempt at endoscopic mucosal resection should be considered. This technique can be performed in a variety of ways: the most common method seems to be through the use of a saline injection, to separate the mucosa-submucosal layer, followed by a cap-assisted snare resection with suction. The safety, efficacy, and outcome of this technique are reviewed. Gastric outlet obstruction remains a difficult problem to treat endoscopically. However, there is some evidence that endoscopic therapy may be successful in benign disease and should be considered prior to surgical intervention.

Home artificial nutrition

Home artificial nutrition is a mature technology that has been with us for over a quarter of a century. Its use appears to be more widespread in the USA than in other western countries. Issues of outcome, ethics, and quality of life are increasingly important. Complications continue to be reported, some newly recognized and some that we must continually relearn.